Provider Demographics
NPI:1497795785
Name:ST PETERS HOSPITAL
Entity Type:Organization
Organization Name:ST PETERS HOSPITAL
Other - Org Name:ST PETERS HOSPITAL REHAB UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-525-1499
Mailing Address - Street 1:315 S MANNING BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208
Mailing Address - Country:US
Mailing Address - Phone:518-275-4087
Mailing Address - Fax:
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1789
Practice Address - Country:US
Practice Address - Phone:518-275-4087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
10005852OtherCDPHP
000022OtherEMPIRE BCBS
NY000400022000OtherNORTHEASTERN
NY00318823Medicaid
000022OtherEMPIRE BCBS